Provider First Line Business Practice Location Address:
2213 SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47807-2422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-223-2054
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2026